Pain I Flashcards
Pain
- Pain: unpleasant sensory and emotional experience of actual or potential tissue damage
- Tissue damage release chemical substances: prostaglandin (PG), bradykinin, histamine, seratonin, substance P
Types of Headaches
-Primary Headaches:
Chronic tension-type headache
Migraine headache
Medication overuse headache
- Secondary Headaches
- Sinus Headache
Tension Type Headaches
Signs and Symptoms
Bilateral, diffuse pain of head: may radiate to neck and shoulders, “tight band” across head, related to stress / anxiety / depression
Location: over top of head, extending to base of skull
Severity: varies
Onset: gradual
Duration: minutes to days
Migraine Headaches
Signs and Symptoms
-With aura (“classic”) or without aura (may last up to 30 minutes), neurologic: flashing areas, blind spots, difficulty speaking, visual or auditory hallucinations
-Followed by throbbing headache pain (if no aura, starts with throbbing pain)
Location: usually unilateral
Onset: sudden
Duration: hours to 2 days
Associated symptoms: nausea/vomiting, photophobia, phonophobia, tinnitus, light- headedness, vertigo
Quality of life: causes absenteeism and lost productivity at work, affects personal relationships
Sinus Headaches
Signs and symptoms
-Onset: simultaneous with sinus symptoms, including purulent nasal discharge
Duration: resolves with sinus symptoms
When to Refer to PCP for Headache
- Severe head pain
- Headaches that persist for 10 days with or without treatment
- Last trimester of pregnancy
- <8 years of age
- High fever or signs of serious infection
- History of liver disease (consumption of alcohol > 3 alcoholic drinks per day)
- Questionable secondary headache
- No formal diagnosis of migraine headache
Non-Medication Therapies for Headache
- Relaxation exercises
- Adequate sleep
- Proper eating habits
- Ice packs
- Pressure to affected area
Osteoarthritis
- A.k.a degenerative joint disease (DJD)
- Weight-bearing
- Breakdown and eventual loss of the cartilage in one or more joints
- Worsens with age
Non-Medication Therapy for Osteoarthritis
- Activity Modification: rest as much as possible, substitute less mechanically stressful activities, assistive aids
- Warm shower or bath
- Ice pack on painful areas
- Light exercise with initial gentle stretching
Assistive Devices for Osteoarthritis
- Wheels
- Hand/wrist savers
- Bathroom benches, raised seats, hand rails
- Kitchen tools / gadgets
Treatment Goals for Pain and Headache
- To alleviate acute pain
- To restore normal functioning
- Prevent relapse
- Minimize side effects
- For chronic headache: to reduce frequency of headaches
- For osteoarthritis: decrease rate of progression of disease with focus on ADLs
Over the Counter Products
-NSAIDs (non-steroidal anti-inflammatory drugs)
Ibuprofen (Motrin®, Advil®)
Naproxen (Aleve®)
Ketoprofen (Orudis®)
-Salicylates: also relieves inflammation
Aspirin (acetylsalicylic acid)
Choline salicylate (Arthropan®)
Magnesium salicylate (Doan’s® )
-Acetaminophen (Tylenol®): not effective for inflammation
NSAIDs: Mechanism of Action
- Inhibit prostaglandin synthesis by inhibiting both isoforms of the enzymes cyclooxygenase (COX-1 and COX-2)
- The resulting decrease in prostaglandins reduces the sensitivity of pain receptors to the initiation of pain impulses at sites of inflammation and trauma
NSAIDs & Aspirin Pharmacology
Cyclooxygenase enzymes
- COX-1: cytoprotection of stomach/intestine and kidneys, and aggregation and vasoconstriction of platelets
- COX-2: pain, inflammatory response induced by macrophages, fribroblasts, platelets
NSAIDS and Aspirin Adverse Effects
- Gastrointestinal
- Renal complications
- Platelet dysfunction/clotting problems
- Cardiac complications
- Hypersensitivity/Allergy
- Reye’s syndrome
- Stevens Johnsons Syndrome
GI Effects
- Local irritant from drug contacting GI mucosa
- Systemic effect from prostaglandin inhibition
- GI bleeds
- High risk: advanced age, alcohol abuse / ingesting with alcohol, liver disease, gastric ulcerations, higher dose or longer duration
- Take with food/milk, combine with PPI/H2
- EC: Do not take with antacids, do not crush or chew EC aspirin
Renal (Kidney) Complications
-Decreased renal blood flow
-Inhibition of protective PGs on kidney
Concerns of concomitant use of NSAIDs/ASA and advanced age, diabetes, hypertension, congestive heart failure, cardiovascular disease (atherosclerosis)
High risk patients should not self-medicate with NSAIDs
Clotting Problems
-NSAIDs will increase risk of bleeding
-Avoid NSAIDs in patients with platelet dysfunction or thrombocytopenia
-Avoid combining NSAIDs with
anticoagulants and antiplatelet meds
-NSAIDs: stop 48 hours before surgery and restart once patient is no longer at bleeding risk
Cardiovascular Side Effects
- NSAIDs associated with increased risk for myocardial infarction, congestive heart failure, hypertension and stroke
- Dose and duration dependent
- American Heart Association recommends that patients with or at high risk for cardiovascular disease should avoid NSAIDs
Aspirin Allergy
- Signs/Symptoms: urticaria (hives), angioedema (rapid swelling of skin mucosa), difficulty breathing, bronchospasm, profuse rhinorrhea, and shock
- Onset: Occurs within 3 hours of aspirin ingestion
- Reye’s Syndrome: Associated with aspirin use (rarely occurs but avoid use in children < 15 yo)
- Applies to all drugs containing salicylates e.g. Pepto-Bismol
- Main effect: increased pressure in the brain and massive accumulations of fat in the liver / other organs
Low Dose Aspirin
Role of low dose aspirin
- Low dose refers to: 81mg po daily or325mg po every other day or 1⁄2 of 325mg tab daily
- This dose does not provide analgesic, antipyretic or anti-inflammatory effects
- Used for prevention of myocardial infarction in high risk patients (e.g. previous MI, CAD, DM)
NSAIDs & Aspirin Interactions
Drug Interactions
- Ibuprofen (and other NSAIDs) may block the cardio-protective effects of aspirin (ASA)
- Competitive inhibition for platelet COX acetylation site
- Give ASA at 1 hour before NSAID OR wait at least 8 hours after administering NSAID to give ASA
Drug-Disease Interactions
-Hypertension, Diabetes Mellitus (DM), Congestive Heart Failure (CHF), Impaired renal function, Gout